Nip, Tuck, and
the Feminine SelfWhy cosmetic surgery is about
more than we think.

By Dr. Loren Eskenazi and Peg Streep |Every year, more and more American women elect to have cosmetic surgery, and the trend shows no signs of abating. Nearly 11 million procedures were performed in 2006, echoing increases in each of the previous five years. No longer the province of the rich and famous, cosmetic surgery has become fully democratized, as available in Peoria as it is in Manhattan or Beverly Hills. A new nose or a trimmer derriere appears to be just another commodity in a consumer society, and a growth business for those who perform it.

But as a plastic surgeon who has performed roughly 10,000 procedures, I don’t think we’ve gotten a handle on how cosmetic surgery changes people or why so many women choose it.

Despite America’s apparent embrace of cosmetic surgerythe rising number of procedures, the reality shows devoted to it, the media attention paid to itour cultural attitudes toward it remain deeply ambivalent. Our culture’s Puritan roots stress that anything good or desirable is worth working for, and consequently we value physical transformation when it involves diet (discipline) and exercise (work). Physical transformation achieved by any other meanssuch as a surgeon’s knifeis something else. Because we distrust the “quick fix,” we’re inclined to believe that anyone willing to choose this “easy” way out must do so because of a character flaw or weakness. Research confirms that most womenand menbelieve that women who have elective plastic surgery are more vain and insecure than those who don’t.

Our suspicions about cosmetic surgery are bolstered by both the Judeo-Christian tradition and the Cartesian divide. The first emphasizes skin as just the envelope of the self, the body as the mere container of the soul. It teaches us that paying too much attention to things that are “only” skin-deep will be detrimental to the health of the spirit. From the second, we glean the notion of the mind/body split, each separate from the other.

These popular conceptions run counter to what modern science has to teach us, and to my own experiences with female patients. Not only are the mind and body not separate, they can interact and change each other. Focusing our thoughts on the color red, for example, will predictably raise our blood pressure and heart rate; imagining the color blue will lower both. A growing body of literature supports the positive effects of visualization and hypnosis for both cancer patients and those undergoing surgery. Neurobiologists are just beginning to tease out how the brain is shaped by sensations perceived through the body. All of this suggests that all surgeryincluding the cosmetic varietyaffects more than just the body itself.

I learned this firsthand years ago from a patient who technically didn’t have surgery at all. A young woman in her early thirties came into my office for a consultation. Except for two very deep frown lines between her eyespronounced enough to be jarring in a youthful faceshe was attractive and articulate. She’d just finished her Ph.D. and was about to get married. To celebrate that new adult life, she wanted to know if Botox would remove her frown lines. I told her that after a few injections, the lines would be diminished. I began her treatment that day.

A week later, she unexpectedly returned to my office. She looked totally worn out. Her eyes were red-rimmed and puffy. I was immediately concerned that she’d had an adverse reaction to the injection, which is unusual but not impossible. What I learned when we sat down together utterly astonished me. She explained that she’d been unable to stop crying for days. When the muscle between her eyes had stopped working, she’d experienced a flood of emotions. Long-forgotten memories of her childhoodof her mother scolding her for not smiling enough, of being told that she looked sad or angry when she wasn’tsuddenly surfaced. The outpouring of memories, which were so vivid that she actually felt as if she were reliving every incident, in turn released pain and anger.

My patient’s experience both humbled and amazed me. How could a single muscle hold so much information? The directness of the connectionincident after incident held by a single, tiny part of the bodywas astonishing. Her experience hinted at the complexity of the connection between the inner and outer self, the layers of emotional experience stored in the body. It was an epiphany for me.

I knew that the mind could change the body; what I hadn’t appreciated fully was the possibility that restructuring the body could transform the mind. And if Botox could be such a powerful emotional catalyst, actual surgery was bound to prompt even more profound responses. I began to ask my patients a simple question, “Why are you choosing to have surgery now?”, and their answers revealed reasons much more complex than the simple desire to look better or younger. Rather than being driven by insecurity or vanity, their narratives of self were rich and compelling, and hinted at explanations very different from the standard answers our society offers about why women seek cosmetic surgery. These narratives are different from those articulated by women who seek out surgery in the hopes of pleasing someone else. I’ve learned to discourage those women from going forward, because they aren’t likely to experience change or, for that matter, satisfaction.

I came to see that there were reasons aside from cultural pressures that could explain why women, more than men, sought out cosmetic surgery. Women and men inhabit their bodies differently, in part because female biology doesn’t easily permit us to see our bodies as mere “envelopes.” Women’s bodies bear witness to the passages of female experiences and the changing selffrom menarche to childbearing to menopausein ways that male bodies, with a simpler reproductive system, do not. There is a sense in which our female identity is indeed embodied.

For all of the culture’s emphasis on the surface of the female bodythe trim thigh, the firm breast, the sculpted derrierewomen know that the body as we experience it from the inside actively forms and shapes the self. The female body and the female self are partners in an intricate dance with identifiable stages or passages.

Yet in our modern culture it is a dance without music, accompaniment, or setting, performed alone, without support. In many pre-modern societies, the stages of a woman’s life were articulated by acknowledging those inner changes with outer-body modifications. These rites put the individual experience of passing between stages of life into a meaningful and symbolic context.

While it may seem radical, most of the women who come into my office, whether they are fully conscious of the underlying motivation or not, seek both physical transformation and physical affirmation of an internal change that has either taken place or is about to. Women about to get married or women who have been through a divorce. Women who have recently cared for an ill or dying loved one. Women who have themselves survived a life-threatening illness. Women who have just been fired, or promoted. Women who have just entered menopause or who have finished the years of childbearing. Women entering a new decade of life.

Over and over, my patients’ own stories attest to the urgent need to make life passages physically manifest, laying claim to the experience on the body in the same way as an adolescent girl will pierce her umbilicus not just as a fashion statement but as a symbolic way of redefining her relationship to her mother. In this important sense, cosmetic surgery has become one way of supplying the support and validation of individual experience our modern society no longer provides.

Loren Eskenazi, M.D., F.A.C.S C’78 is the founder of the nation’s only three-woman plastic surgery group. Peg Streep CW’69 is the author andco-author of nine books, including More Than Skin Deep, from which this essay was adapted.